HomeMy Public PortalAbout5841 ROWLAND AVE_Sewer__ 76808 3-64
76A642D APPLICATION' FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
LAMBIE. County Engineer
ADORE S V"
JOHN A.
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
Ci
NEAREST
CROSS
FOR APPLICANT TO FILL IN
LE—GA L
DESCRIPTION LOT NO. OWNER
S
A DD R ES
LOCALITY TY
U__
EST
NEAR
ROS S .1
W NE.
MAIL
BLOCK TRACT ADDRESS
C� NO. OF SL GS.
SIZE OF LOT NOW N LT
_-N. -0 CITY TEL. NO,
USE OF DISTRICT NO. GROUP PROCESSED BY
P
BUILDINGS MASK FG
CONTRACTOR C), ILI
ADDRESS 7 i CONNECTION
CITY TEL. NO. ff 4"k- STATION � ./ DEPTH
STATE E REFERENCE
REGISTRATION NO... 4`1 IQL COUNTY MANHOL �Q LOWER
CRIPTION OF WbREE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. C M,L.TO P.L.
PUBLIC SEWER @ $5.00 P.C.NO.
SEPTIC"_T_,�_N_K.SEEPAGE PIT OR
JOB NO,
PITS AND/OR DRAINFIELD $10.00 CO.IMP,NO. I 'j
0
HOUSE S EWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL SLOG.OR !ECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER 0
0v
ERFLO $3.00 W SEEPAGE PIT,GRAINFIELD U
EXTN,CESSPOOL,DRYWELL.MANHOLE $5.00
i
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST,WIDENING 'e-jkL:, W
SEWER OR DISPOSAL SYSTEM $3.00
STATE ENCROACHMENT U)
PERMIT NO. z
'r;.ic INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2i 00
CONNECTION CHARGE PEE
AUTHORIZATION TOTAL FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR T CO IN N ECT THE ABOVE DESCRIBED EXISTING DWELLING
0 1 INSPECTOR'S SIGNATURE
T THE PUBLIC SEWER. APPROVALS DATE
SIGNED THIS—DAY OF-19—
OWNER OR NEW HOUSE SEWER
OWNERS AGENTCONNECTADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS
APPLICATION AND/OR 0,RAINFIELD
AND
S TATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY
ORD INANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL 0 DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REOUzRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO --6—,,,ENNECT PLUG AND
RESIDE
IN, THE. ABOVE
DESCRIBED
RESIDENTIAL PROPERTY. ABANDON
ON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
I &,-' 'e - —I " -/,, — -
OF PERMITTEE ,
SEEP.PIT IS) ❑ CESSPOOLS ❑
VA TION ROBERT A. WOOD
CK. SUPERVISING MECHANICAL ENGINEER
17,
9 U 5 2 U4 13